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  1. Patient Identification Errors: A Systems Challenge | PSNet

    psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
    February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49612/psn-pdf
    November 01, 2010 - Treatment Challenges After Discharge November 1, 2010 Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge Case Objectives Understand types and frequencies of adverse events occurring between patient discharge from the hospital …

  3. Hard to Swallow | PSNet

    psnet.ahrq.gov/web-mm/hard-swallow
    April 26, 2023 - Hard to Swallow Citation Text: Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  4. The Dropped "No" | PSNet

    psnet.ahrq.gov/web-mm/dropped-no
    October 30, 2019 - The Dropped "No" Citation Text: Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73650/psn-pdf
    August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49568/psn-pdf
    September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…

  7. Haste Makes Care Unsafe | PSNet

    psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - Haste Makes Care Unsafe Citation Text: Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  8. Discharge Instructions in the PACU: Who Remembers? | PSNet

    psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
    August 05, 2009 - Discharge Instructions in the PACU: Who Remembers? Citation Text: Engel KG. Discharge Instructions in the PACU: Who Remembers?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar B…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49869/psn-pdf
    July 02, 2019 - Failure to Rescue the Mother July 2, 2019 Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/failure-rescue-mother The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding. An …

  10. Fire in the Hole!—An OR Fire | PSNet

    psnet.ahrq.gov/web-mm/fire-hole-or-fire
    August 03, 2017 - Fire in the Hole!—An OR Fire Citation Text: Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865374/psn-pdf
    March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges March 27, 2024 Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges Introducti…

  12. Pocket Syringe Swap | PSNet

    psnet.ahrq.gov/web-mm/pocket-syringe-swap
    July 01, 2006 - Pocket Syringe Swap Citation Text: Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

  13. Diagnostic Overshadowing Dangers | PSNet

    psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
    February 12, 2020 - Diagnostic Overshadowing Dangers Citation Text: Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  14. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
    May 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case May 2008 Diagnosing HIV: It Doesn’t Take a Brain Surgeon Source and Credits This presentation is based on the May 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Roger Chou, MD, Oregon Health &…

  15. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
    June 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case June 2007 Beeline to Spine Source and Credits This presentation is based on June 2007 AHRQ WebM&M Spotlight Case See full article at http://webmm.ahrq.gov CME credit is available online Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49440/psn-pdf
    March 01, 2004 - Autopsy Revelation March 1, 2004 Shojania KG. Autopsy Revelation. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/autopsy-revelation The Case A 45-year-old male with development delay presented to the emergency department with acute abdominal pain. His mother, who was his main caregiver, accompanied him. Th…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49475/psn-pdf
    March 01, 2005 - Techno Trip March 1, 2005 Cook RI. Techno Trip. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/techno-trip The Case A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49594/psn-pdf
    December 01, 2009 - Standard Deviations December 1, 2009 Sabin JE. Standard Deviations. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/standard-deviations Case Objectives Understand the safety risks associated with patients being discharged against medical advice (AMA). Recognize safety risks associated with being part of a …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49664/psn-pdf
    January 01, 2013 - Empty Handoff September 1, 2012 Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/empty-handoff The Case A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic…

  20. No BP During NIBP | PSNet

    psnet.ahrq.gov/web-mm/no-bp-during-nibp
    March 01, 2011 - No BP During NIBP Citation Text: Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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